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TeemuLuoto
TopiLuoto

Head Injuries in Children

Essentials

  • Most head injuries in children do not suggest brain injury, and the diagnosis is based on clinical assessment.
  • Assess the need for monitoring in hospital and for CT based on patient history and clinical findings.
  • Consider the possibility of concomitant cervical spine injury.

Background

  • Traumatic brain injury is a functional disorder of the brain caused by an external force. More severe injuries also involve structural lesions that can be detected by imaging.
  • In a European study on traumatic brain injury, wide variation between countries was found in the mortality and hospital discharge rates. The lowest mortality rate was 0.5 (Ireland, girls) and the highest 11.4 (Lithuania, boys) per 100 000 http://academic.oup.com/eurpub/article/28/suppl_4/cky214.043/5186312. Hospital discharge rates varied from 36.3 (Iceland, girls) to 1019.9 (Germany, boys) per 100 000. The pooled age-adjusted hospital discharge rates were 422.8 (boys) and 281.6 (girls) per 100 000. Another, global study also reported great variation between countries in the incidence of traumatic brain injury, in most countries 47-280 per 100 000 http://www.sciencedirect.com/science/article/abs/pii/S1878875016004642.
  • The most common injury mechanisms are falling from a height or from standing and traffic accidents. The possibility of physical abuse must also be kept in mind.
  • Brain injuries are classified as mild (approx. 90% of cases), moderately severe (approx. 5%) or severe (approx. 5%).
  • CT is done for only approx. 10% of children with head injury, and brain injuries are found in 4-6% of these. Only approx. 0.1% of all children with head injury need neurosurgical treatment.

Signs and symptoms of brain injury and related findings

  • Most head injuries in children do not suggest brain injury or the injury is no more severe than concussion (= very mild brain injury).
    • In concussion, the disturbance of brain function caused by the head injury is transient and of short duration and involves no more than momentary unconsciousness or amnesia and no imaging findings.
  • The diagnosis of brain injury is based on the following: Glasgow Coma Scale (GCS) score, unconsciousness, posttraumatic amnesia (PTA; a memory gap after injury) and brain imaging findings (CT and/or MRI). In most children, the diagnosis is purely clinical.
  • Definition of the clinical severity of brain injury
    • Mild brain injury: GCS 13-15, unconsciousness < 30 min, PTA < 24 h
    • Moderately severe brain injury: GCS 9-12, unconsciousness 30 min - 24 h, PTA 24 h - 7 days
    • Severe brain injury: GCS 3-8, unconsciousness > 24 h, PTA > 7 days
  • Use the version of the Glasgow Coma Scale appropriate for the child's age (Table T1).
  • The duration of unconsciousness should be determined based on information provided by an eye witness because the patient cannot distinguish between a period of unconsciousness and PTA.
  • PTA covers the period after the injury of which the patient has no continuous memory. This period typically leaves a permanent memory gap because during PTA the brain cannot form permanent memory traces of any events. In smaller children, it is not possible to define PTA reliably.
  • Other possible (non-diagnostic) symptoms associated with brain injury include headache, nausea, vomiting, balance problems, drowsiness, fatigue/fatigability and concentration and memory problems. Such symptoms also occur in a significant number of patients with head injury without clinical signs of brain injury.

Paediatric Glasgow Coma Scale

FunctionResponseScore
2 years of age or olderBelow 2 years of age
Eye openingSpontaneous
To verbal command
To pain
No response		Spontaneous
To verbal command
To pain
No response		4
3
2
1
Best verbal responseOriented
Disoriented, sentences
Single words
Incomprehensible sounds
No response		Follows, recognizes objects
Cries, irritable; follows objects at times
Cries to pain, can be woken up
Moans to pain, cannot be woken up
None, no vocal response		5
4
3
2
1
Best motor responseObeys commands
Localizes pain
Withdraws to pain by flexion
Flexion to pain (abnormal)
Extension to pain
No response		Normal spontaneous movements
Withdraws to touch
Withdraws to pain
Flexion to pain (abnormal)
Extension to pain
No response		6
5
4
3
2
1
Total3-15

Assessment in the acute situation

  • Assess whether the energy involved was sufficient to cause a brain injury.
  • Assess the patient's orientation to time, place and person (i.e. him/herself) at presentation and during follow-up.
  • Assess any PTA and its length by repeated, detailed questions.
  • Enter the exact time of injury and the end of PTA in the patient record.
  • Clinical examination should exclude local neurological symptoms and findings.
  • Note any external injuries particularly in the area of the head or face, and enter any findings in the patient record.
  • Palpate the skull to find any signs of fracture.
  • Blood in the middle ear (haemotympanum) and subcutaneous haematomas around the eyes (bilateral periorbital haematoma, "raccoon eyes") or behind the ears (Battle's sign) may suggest basal skull fracture. A rarer sign of basal skull fracture is CSF leak from the nose or the ear.
  • Skull x-ray or ultrasonography is not helpful when assessing the need for treatment for an acute brain injury.
  • The possibility of cervical spine injury should always be kept in mind when assessing patients with head injury.
  • Indications for emergency cranial CT are presented in a flowchart in the Scandinavian guidelines for initial management of minor and moderate head trauma in children (see Figure 6 http://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-0574-x/figures/6).
  • Consulting a neurosurgeon
    • Emergency neurosurgical consultation is warranted to determine the appropriate treatment of acute intracranial injury detected by CT.
    • Neurosurgical consultation regarding the need for imaging in children below 2 years with head injuries is warranted if there are worrying signs or symptoms (such as decreased alertness, bulging fontanelle, recurrent vomiting, ictal symptoms).

Treatment

Treatment in the acute situation

  • Most patients with head injury can be treated without CT. Some patients should be monitored in hospital after injury. Indications for CT and monitoring are presented in the aforementioned flowchart http://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-0574-x/figures/6.
  • The patient can be discharged if the level of consciousness is normal and there are no indications for imaging or monitoring (flowchart http://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-0574-x/figures/6). If the patient is discharged, provide the child's parents/guardians adequate oral and written information on how to monitor the child at home and how and when to seek further medical help after discharge.
    • In practice, neurologically intact children over 2 years of age with no recurring vomiting, severe headache, ictal symptoms, clinical signs of skull fracture, unconsciousness, amnesia or parent worrying about their condition can be discharged from the emergency department without CT (except for children with shunt).
  • The purpose of hospital monitoring is to treat the symptoms and to recognize rare delayed intracranial bleeding if the patient's condition deteriorates. In case of mild injury, monitoring is often carried out in a paediatric or paediatric surgical ward.
  • Hospital monitoring should cover
    • the level of consciousness (GCS)
    • limb movement and speech
    • vital functions (blood pressure, heart rate, respiratory rate and oxygen saturation)
    • in children below 2 years of age, bulging of the fontanelle.
  • These should be assessed
    • 0-6 h from injury every 30 minutes
    • 7-12 h from injury hourly
    • 13-24 h from injury every 2 hours.
  • If the neurological status deteriorates during monitoring (new neurological finding, increasing signs or symptoms and/or GCS score decreased by ≥ 2 points), cranial CT should be performed without delay and a neurosurgeon consulted.
  • In moderately severe or severe brain injury, brain MRI is indicated later to determine the extent of the structural injury. MRI is typically done during the period of primary treatment.
  • In the case of mild brain injury, MRI during the period of primary treatment should be performed if:
    • The cranial CT findings on admission are consistent with an injury
    • There are severe signs or symptoms (such as headache, nausea, vomiting) on the day after the injury, preventing discharge or
    • There was a high-energy injury (such as a traffic accident or falling from a height > 3 m).
  • Symptomatic medication on the ward
    • For headache, the first-line drug is paracetamol
    • Additionally an NSAID as required for pain when more than 24 h have elapsed since the injury
    • For nausea, antiemetics (such as metoclopramide or ondansetron), as necessary

Recovery and follow-up

  • Recovery from concussion typically takes from a few days to a few weeks. Recovery from mild brain injury may take several months. Moderately severe or severe brain injuries often have permanent sequelae; the most significant recovery will take place within the first 1-2 years.
  • In the case of mild or very mild injury (= concussion), rest or reducing mental or physical exertion, at least, is indicated for 1-2 days. Physical and mental/cognitive exertion can then be gradually increased.
    • A child with concussion can usually return to daycare or school in 1-3 days.
    • Physical hobbies can be resumed as soon as symptoms have subsided almost completely and are no longer provoked by exertion.
  • In the case of concussion, there is no need to arrange routine checkups. Parents should be instructed to contact health care if symptoms persist 1 month after injury.
  • After mild brain injury, recovery should be followed up after about 1 month in an outpatient clinic at a hospital unit treating paediatric brain injuries (by phone, at least).
  • Patients with prolonged symptoms (> 1 month) after mild injury should be referred for further paediatric neurological investigations.
  • If the brain injury is more severe than mild, a follow-up and rehabilitation plan should be made during acute treatment on the ward.

Long-term effects

  • There is no unequivocal evidence available on cumulative adverse effects (such as increased or prolonged symptoms after recurrent injuries) or long-term effects (such as neurodegenerative diseases, incl. chronic traumatic encephalopathy) of single or recurrent concussions or mild brain injuries.

    References

    • Reed N, Zemek R, Dawson J, Ledoux AA, Provvidenza C, Paniccia M et al . Living Guideline for Pediatric Concussion Care [Internet]. 2021. Available from http://www.pedsconcussion.comhttp://doi.org/10.17605/OSF.IO/3VWN9
    • Babl FE, Tavender E, Ballard DW et al. Australian and New Zealand Guideline for Mild to Moderate Head Injuries in Children. Emerg Med Australas 2021;33(2):214-231. [PubMed]
    • Lumba-Brown A, Yeates KO, Sarmiento K et al. Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children. JAMA Pediatr 2018;172(11):e182853. [PubMed]
    • Astrand R, Rosenlund C, Undén J et al. Scandinavian guidelines for initial management of minor and moderate head trauma in children. BMC Med 2016;14():33. [PubMed]